The Total Submuscular Breast Augmentation

Advances in Plastic & Reconstructive Surgery © All rights are reserved by Richard Moufarrège, et al. Review Article ISSN: 2572-6684 The Total Submuscular Breast Augmentation Richard Moufarrège1, George Dimitropoulos1, Hussein Assi2 1University of Montreal Hospital Centre (CHUM). 2Department of Medicine, University of Montreal. Abstract Most called retromuscular or retropectoral breast augmentations consist in inserting the prosthesis behind only one muscle on the anterior aspect of the thorax, that is to say behind the pectoralis major muscle. This will mean that one third or one quarter of the prosthesis will not have a muscular cover and will be in direct contact with the breast tissue. The lack of muscle protection on a part of the prosthesis surface will lead to a possible wrinkling show on the inferior lateral aspect of the breast and a possible “double-bubble” phenomenon. These two disadvantages could be circumstantial but there is one other inconvenience, much more frequent, which is the loss of the erogenous sensation of the nipple. That problem is a consequence of the prosthesis insertion behind the only pectoralis major muscle, interrupting often the continuity of three intercostal nerves (4th, 5th and 6th), responsible of erogenous sensation of the nipple. Our approach promotes the insertion of the prosthesis behind the four muscles of the anterior thorax through a low incision in the anterior oblique and the serratus anterior, and an undermining superiorly, medially and laterally to create a pocket behind the four muscles: the anterior oblique, the serratus anterior, the pectoralis minor and the pectoralis major. This surgery will preserve the functions of the three intercostals nerves, thus the erogenous sensation and contraction of the nipple and nipple areola complex. Keywords: Breast augmentation; Retropectoral Augmentation; Total Submuscular Augmentation; Erogenous Sensation of the Nipple; Double-Bubble Avoidance. Introduction upper two-thirds or three-quarters. That means that one-quarter or one-third of the breast does not cover the pectoralis major muscle but The simple subpectoral breast augmentation is known since only a small part of the pectoralis minor, the serratus anterior and the several decades. This technique has gained popularity for many external oblique muscle. reasons, such as the support of the implant by a muscular hammock reducing the pressure on the skin envelope, which otherwise would Classically, the majority of surgeons who perform the subpe- have to support exclusively the implant. The second advantage of this ctoral approach in breast augmentation, whether for aesthetic or technique was the presence of a thick muscular layer between the reconstruction augmentation, make their incision in the inframa- implant and the skin, especially in case of a small-sized or an mmary fold [Figure 1], dissect from caudal to cranial from the involuted breast. The most important factor which popularized the incision level in a retroglandular plan until the inferior lateral border submuscular technique was the tremendous increase of the use of of the pectoralis major. At this level, they elevate the pectoralis major saline implants during and after the “silicone crisis” in the 1990s. The and thus create the pocket meant to receive the implant. However, saline implants presented the drawback of implant rippling when they the implant, which is destined to increase the volume of the breast or, were placed in the subglandular space because the breast tissue did in case of a mastectomy, to replace the missing breast, has to respect a not offer enough thickness to cover the rippling. The adoption of the precise position and cannot lie into a hazardous position. Inversely, subpectoral approach gave a supplementary layer of tissue in front of the implant cannot be hidden completely under the pectoralis major the implant and so the rippling was efficiently covered. muscle because otherwise it will become deformed [Figure 2a & 2b]. The standard approach in subpectoral breast augmentation This leads to an unavoidable result: with the simple subpectoral breast augmentation, the pectoralis major can cover the two-thirds or This technique, as its name mentions, consists of inserting the at best three-quarters of the implant. One-third or one-quarter of the implant under the pectoralis major muscle. implant is only covered by the breast on its inferior lateral aspect According to the anatomical studies of the thoracic wall, the fan- [Figure 2a & 2b]. shaped pectoralis major muscle, which extends from the axilla to the While the central part of the implant is covered by the pectoralis sternum, is in close relation with the posterior face of the breast on its major muscle and the existing breast, the lateral part of the implant is sometimes only covered by the skin in the cases of small or involuted *Address for Correspondence: Dr. Richard Moufarrège, MD, FRCS (C), breasts. The consequence is having the effect of “fleur de peau” (in Professor of Plastic Surgery at University of Montreal, 1111 St-Urbain, Suite case of thin-skinned patients) and the presence of rippling at the 106, Montreal, Qc, H2Z 1Y6, Canada, Tel: (514) 944-6688; E-Mail: lateral aspect of the breast. The rippling is present even in the case of [email protected] silicone cohesive implants, in various degrees ranging from the Received: October 08, 2018; Date Accepted: December 27, 2018; Date perception of these folds only by touch to visible rippling in most Published: December 28, 2018. serious cases. Adv Plast Reconstr Surg, 2018 Page 237 of 241 useful characterization of serotonin receptor subtypes in the treatment of Richard M, George D, Hussein A. The Total Submuscular Breast Augmentation. Adv Plast Reconstr Surg, 2018; 2(4): 237-242. Literature review According to the literature, the majority of surgeons use the simple subpectoral approach in their submuscular breast augmentation procedures. Maher et al.1, Matarasso2, Tebbetts3,4, Davidson5, Strasser 6, De Haan et al.7, Lesavoy et al.8, Zeitouné et al.9, Hage et al.10, Shi et al.11 and Vidya et al.12 perform breast augmentation behind the pectoralis major which implies that one third of the prosthesis is not covered by the muscle in its inferior lateral aspect. Graf et al. [13] and Tebbetts [14] proceed behind the pectoralis major fascia using a submammary approach. Skin incision Pelle-Ceravolo et al. [15] creates his implant pocket behind the pectoralis major using a vertical incision behind the lateral free edge of the muscle. Barnett [16] prepares his implant pocket using a retrofascial approach of the pectoralis major trough an axillary passage. Figure 1: Breast total submuscular augmentation: skin incision in the subma- Price [17] advocates the subpectoral addition using the axillary mmary fold. approach. 1. Sternum Pound [18] and Rinker [19] use a retropectoral approach starting 2. Pectoralis major from the abdomen. 3. Prosthesis contour limit 4. Pectoralis minor All the authors mentioned above therefore use an approach 5. Pectoralis major 1 6. Prosthesis behind the pectoralis major muscle whether submuscular or subfa- 7. Skin incision (level) 2 scial to perform breast augmentation. Consequently, one third of the 8. Serratus anterior muscle prothesis does not get its surface covered by any muscle. 4 3 9. External oblique muscle 10. Rectus abdominis 5 Hendricks [20] appears to be the only author presenting breast augmentation behind the four muscles using, however, a periareolar approach. This allows him to penetrate the submuscular space 6 centrally and dissect centrifugally an implant pocket behind the four muscles of the anterior hemithorax. This approach, however, puts in 7 danger the continuity of the intercostal nerves even though, in some 8 cases, we can hope for nerve sparing. 10 Finally, our literature review reveals that only Hendricks places the prosthesis behind the four muscles of the anterior hemithorax. However, his approach differs from ours in that he creates a submuscular implant pocket trough a breach in the pectoralis major muscle and a centrifugal dissection. This approach cannot ensure the Figure 2a: Traditional retropectoral augmentation : Insertion of the prosthesis integrity of the intercostal nerves. under the pectoralis major Our approach, which consists in undermining the four muscles starting from a horizontal incision in the external oblique and the 1 serratus anterior muscles is the only way to preserve nerve integrity 2 and thus the erogenous sensation of the nipple. 3 4 Breast reconstruction by subpectoral implant 5 In case of retropectoral breast reconstruction, the mastectomy 6 that precedes leaves the implant without any breast coverage in the 7 1. Intercostal nerve (5th or 6th extremity) inferior lateral third of the breast surface and therefore the prosthesis 8 2. Breast gland tissue 9 3. Pectoralis major muscle will sit in the subcutaneous layer on its lateral anterior aspect. That’s 4. Prosthesis 10 why surgeons are obliged to use dermal matrices in order to restore 5. Interrupted intercostal nerve the lack of muscular support of the implant. We all know the inherent 6. External oblique muscle 7. Interrupted intercostal nerve risk of these matrices in terms of seroma (risk multiplied by four) and 8. Pectoralis minor infection (risk multiplied by five and a half) [21-26]. 9. Serratus anterior muscle 10. Serratus anterior muscle Breast augmentation by axillary approach 11. Rib 12. Intercostal nerve (5th or 6th) The breast augmentation by axillary approach is attractive by the fact that it gives the impression of protecting the implant by the absence Figure 2b: Traditional retropectoral augmentation: Transverse section of the of incision in the inframammary fold. In fact, once the implant has breast following insertion of the prosthesis. Adv Plast Reconstr Surg, 2018 Page 238 of 241 Richard M, George D, Hussein A. The Total Submuscular Breast Augmentation. Adv Plast Reconstr Surg, 2018; 2(4): 237-242. passed under the humeral portion of the pectoralis major, it is inserted into the pocket covered by the pectoralis major at its upper medial two-thirds or three-quarters.

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